Medical misadventure verdict at Kerry maternal death inquest

The jury finds that the death of Tatenda Mukwata, 34, after giving birth to her fourth child ‘was probably preventable’

Tatenda Mukwata, who died after giving birth to her fourth child.

The jury at the inquest into a maternal death in Tralee in April 2022 has returned a unanimous verdict of medical misadventure.

Tatenda Mukwata, aged 34, a mother of three, late of Atlantic Lodge, Kenmare, Co Kerry, died after giving birth to her fourth child.

She died at University Hospital Kerry (UHK) Tralee on April 21, 2022.

In its findings, the jury said “this was probably preventable”.

“There was a misdiagnoses followed by a failure to investigate other possible differential misdiagnoses,” the jury said.

The cause was a catastrophic bleed haemorrhage and shock due to uterine arterial malformation following a caesarian section.

Recommendations

The jury made seven recommendations including that clinicians need to heed nurses concerns; investigate all likely causes of diagnoses; staff should not be required to work excessive hours on health and safety grounds; establish an emergency response team in the maternity unit with proper training and education on haemorrhage policies; review laboratory communication procedure; and review efficiency.

It also recommended “an electronic record system be brought back in all sections in UHK, the south-west hospital group, and HSE network, with appropriate cyber network protection”.

Routine early post-partum blood tests for haemoglobin should also be introduced.

Sympathy was extended to the family by all concerned and the jury commended for its attentiveness.

Earlier, a consultant obstetrician who was in charge of women in labour at UHK when Ms Mukwata died said at no stage was she warned of a concern about the possibility of bleeding.

Dr Mary McCaffrey said she had seen Ms Mukwata at 5pm and examined her.

The on-call registrar Dr Fahad Hendricks and two nurses in post-operative care suspected sepsis was setting in. Dr McCaffrey asked about the possibility of bleeding and was told there was no obvious sign of bleeding.

Dr Hendricks too was “absolutely confident” there was no bleeding.

At 9.15pm, Dr McCaffrey requested bloods but was told they weren’t done.

“I was taken aback because I assumed the sepsis protocol had kicked in,” she said. She ordered this to be done.

Had the bloods been done in a timely manner, and the results back quickly from the lab, in accordance with the national protocol on sepsis, the haemorrhaging would have been detected, she said.

The staff nurse had concerns at that stage it was sepsis, she said.

“This was understandable, as sepsis had been a focus by everyone since the death of Savita Halappanavar,” she said.

“One thing we don’t do in UHK in the operating theatre and it might be a recommendation, is electronic records,” she told the inquest.

Since the cyberattack on the HSE, the operating theatre had returned to paper records.

“Since the cyber hack, it is quite hard to look at trends,” she said.

At no stage did a nurse ring her directly as they “not infrequently” did during her 25 years at UHK to elevate their later concerns about bleeding, rather than sepsis, she said.

Both nurses and new doctors could ring consultants directly, she said.

Had the bleeding been recognised, it would still have been quite a complicated surgery, Dr McCaffrey also said, replying to John O’Mahony, counsel for the Mukwatas.

Cause of death

The inquest in August was told an arterio venous malformation (AVM) pre-existing, caused the haemorrhage and led to the death.

The AVM was the cause of the death, Dr McCaffrey said.

“She was bleeding from the arteriovenous malformation, nowhere else.

“We would have done the surgery, but people have to understand, it wouldn’t have been simple,” Dr McCaffrey, who is now retired, said.

At this stage, coroner Helen Lucey and Mr O’Mahony intervened to say the HSE had apologised for failings that led to the death.

At the end of her evidence, Dr McCaffrey tearfully addressed the mother and daughter of the deceased.

She said she was so sorry that this had happened on her watch and to please tell baby Eva when she was older they had exchanged a lot of banter and to tell Eva her mother loved her and was so excited about her and looking forward to going home with her.